Rolf Nitsche

Early ERCP and Papillotomy Compared with Conservative Treatment for Acute Biliary Pancreatitis

BACKGROUND The role of early endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy in the treatment of patients who have acute biliary pancreatitis without obstructive jaundice is uncertain. METHODS We conducted a prospective, multicenter study in which 126 patients were randomly assigned to early ERCP (within 72 hours after the onset of symptoms) and endoscopic papillotomy for the removal of stones in the common bile duct, when appropriate, and 112 patients were assigned to conservative treatment. In the conservative-treatment group, ERCP was performed within three weeks if signs of biliary obstruction or sepsis developed. Overall mortality, mortality due to pancreatitis, and complications were compared in the two groups. RESULTS Early ERCP was successful in 121 of the 126 patients in the invasive-treatment group. Endoscopic papillotomy was performed to remove bile-duct stones in 58 patients; stones were successfully extracted in 57. ERCP was performed in 22 of the 112 patients in the conservative-treatment group; papillotomy for stone removal was successful in 13 patients. Fourteen patients in the invasive-treatment group and 7 in the conservative-treatment group died within three months (P=0.10); 10 patients in the invasive-treatment group and 4 in the conservative-treatment group died from acute biliary pancreatis (P=0.16). The overall rate of complications was similar in the two groups, but patients in the invasive-treatment group had more severe complications. Respiratory failure was more frequent in the invasive-treatment group, and jaundice was more frequent in the conservative-treatment group. CONCLUSIONS In patients with acute biliary pancreatis but without obstructive jaundice, early ERCP and sphincterotomy were not beneficial.

Evidence for an anion exchange mechanism for uptake of conjugated bile acid from the rat jejunum

Absorption of conjugated bile acids from the small intestine is very efficient. The mechanisms of jejunal absorption are not very well understood. The aim of this study was to clarify the mechanism of absorption of conjugated bile acid at the apical membrane of jejunal epithelial cells. Brush-border membrane vesicles from intestinal epithelial cells of the rat were prepared. Absorption of two taurine-conjugated bile acids that are representative of endogenous bile acids in many variate vertebrate species were studied. In ileal, but not jejunal brush-border membrane vesicles, transport of conjugated bile acids was cis-stimulated by sodium. Transport of conjugated bile acids was trans-stimulated by bicarbonate in the jejunum. Absorption of conjugated dihydroxy-bile acids was almost twice as fast as of trihydroxy-bile acids. Coincubation with other conjugated bile acids, bromosulfophthalein, and DIDS, as well as by incubation in the cold inhibited the transport rate effectively. Absorption of conjugated bile acids in the jejunum from the rat is driven by anion exchange and is most likely an antiport transport.Absorption of conjugated bile acids from the small intestine is very efficient. The mechanisms of jejunal absorption are not very well understood. The aim of this study was to clarify the mechanism of absorption of conjugated bile acid at the apical membrane of jejunal epithelial cells. Brush-border membrane vesicles from intestinal epithelial cells of the rat were prepared. Absorption of two taurine-conjugated bile acids that are representative of endogenous bile acids in many variate vertebrate species were studied. In ileal, but not jejunal brush-border membrane vesicles, transport of conjugated bile acids was cis-stimulated by sodium. Transport of conjugated bile acids was trans-stimulated by bicarbonate in the jejunum. Absorption of conjugated dihydroxy-bile acids was almost twice as fast as of trihydroxy-bile acids. Coincubation with other conjugated bile acids, bromosulfophthalein, and DIDS, as well as by incubation in the cold inhibited the transport rate effectively. Absorption of conjugated bile acids in the jejunum from the rat is driven by anion exchange and is most likely an antiport transport.

On the pathogenesis and clinical course of mesenteric lymph node cavitation and hyposplenism in coeliac disease

Background: Coeliac disease is a disorder characterised by malabsorption related to abnormal small bowel structure and intolerance to gluten. There are several reports of an increased risk for malignancy in coeliac disease and its relation to gluten-free, reduced gluten, or normal diet. While a normal diet is associated with an excess of cancer of the mouth, pharynx, oesophagus, and also of lymphoma, treatment with a gluten-free diet restores the cancer risk back to normal. Patient: In the present study, we report on a 63-year-old female patient with a history of coeliac disease for twenty years who presented with persistent diarrhoea, weight loss, and an abdominal mass. Results: The gastroenterological work-up revealed small bowel mucosal atrophy, absence of functional splenic tissue, and evidence for an involution of a mesenteric lymph node, termed cavitation. Discussion: This triad has been previously described to represent a rare disease entity related to coeliac disease. We report a two-year follow-up and a review of the literature on the pathogenesis, prognosis, and therapeutical implications of this disease entity.

Crohn’s Disease Mimicking Sarcoidosis in Bronchoalveolar Lavage

Granulomatous disorders like sarcoidosis or Crohn’s disease are commonly associated with extrapulmonary or extraintestinal manifestations which occasionally may represent the only symptoms. We describe a 28-year-old female patient suffering from atypical erythema nodosum and arthritis. Although the chest x-ray was unremarkable bronchoalveolar lavage revealed lymphocytic alveolitis with an elevated CD4/CD8 ratio of 8 and 11.4 at repeated examinations suggesting a diagnosis of sarcoidosis. Further diagnostic workup included endoscopy of the bowel. The macroscopic aspect and histology of the terminal small bowel and colon ascendens indicated Crohn’s disease. The patient recovered on steroids and sulfasalazine. Six months later she developed a perianal abscess for which she needed surgery supporting the diagnosis of Crohn’s disease. This is the first case of a significantly (>6) elevated CD4/CD8 ratio in Crohn’s disease previously regarded as highly specific for sarcoidosis.

Budd-Chiari Syndrome as the Primary Manifestation of a Fibrolamellar Hepatocellular Carcinoma

An 18-year-old female patient was admitted with ascites, right upper abdominal tenderness and peripheral edema. Angiography showed complete occlusion of the vena cava inferior up to the level of the right atrium. By open heart surgery, masses of thrombotic material were pulled out of the v. cava inferior/vv. iliacae which histologically contained tumor cell populations consistent with a hepatocellular carcinoma. Celiacography showed a highly vascularized tumor in the right hepatic lobe. Histologically, it proved to be fibrolamellar subtype hepatocellular carcinoma.

Prozessentwicklung in der Herzinfarktversorgung

ZusammenfassungDie schnelle Wiedereröffnung des verschlossenen Herzkranzgefäßes ist beim akuten ST-Hebungsinfarkt (STEMI) ein wesentlicher Faktor für die Prognose des Patienten. Der Wettlauf mit der Zeit bis zur Wiedereröffnung kann aber nur gewonnen werden, wenn eine hierauf eingerichtete Basisstruktur geschaffen wird, die durch ein systematisches Qualitätsmanagement (QM) in allen Details und im Zusammenspiel begleitet und kontinuierlich optimiert wird.Zur notwendigen Basisstruktur gehört die Einrichtung eines Herzinfarktnetzes, das in einer bestimmten Region die Möglichkeit zur rund um die Uhr verfügbaren Akut-Koronarintervention schafft und auch die Krankenhäuser involviert, die selbst kein Herzkatheterlabor vor Ort zur Verfügung haben. Ein weiterer wichtiger struktureller Schritt ist die Ausrüstung des Rettungsdiensts mit Zwölf-Kanal-EKG-Systemen, die die EKG-Daten mittels Telemetrie an das Interventionszentrum übermitteln können. Dadurch können auf der Basis einer raschen und sicheren Diagnose des STEMI im Interventionszentrum und der Rückmeldung an den Rettungsdienst zwei wesentliche Ziele realisiert werden, die zu erheblichen Zeitgewinnen führen: 1. das organisierte „Bypassing der Nichtinterventionsklinik“ und 2. das systematische „Bypassing der Notaufnahme“ der Interventionsklinik.Ein effizientes Instrument zur Verbesserung des komplexen Prozessablaufs und zur Verkürzung der Zeitintervalle ist die Etablierung eines standardisierten QM-Systems. Dies beinhaltet die formalisierte Datenerfassung und -analyse sowie die systematische Ergebnisrückkopplung an alle in der Frühphase des STEMI an der Behandlung der Patienten beteiligten Personen und Systeme innerhalb des Herzinfarktnetzes. Eine wichtige Voraussetzung für den positiven Effekt einer solchen Rückkopplung auf die Ergebnisqualität ist, dass die vor Ort erfassten Daten von allen Beteiligten als nachvollziehbar und valide angesehen werden können. Daher sollten die Datendokumentation und -analyse überprüfbar gemacht werden.Bewertende Vergleiche unterschiedlicher Krankenhäuser, Rettungsdienste und Regionen zeigen sich als ausgesprochen problematisch. Hier spielen lokale Besonderheiten und auch der Einschluss oder Ausschluss von STEMI-Patienten mit hohem Mortalitätsrisiko, die unbedingt einer raschen interventionellen Behandlung zugeführt werden sollten, sowie die Gefahr eines missbräuchlichen Einsatzes aus reinen Wettbewerbsgründen eine Rolle. Vergleiche von Behandlungszeiten und Sterblichkeiten sollten daher möglichst ausschließlich innerhalb eines festen Systems vor Ort in einem „Vorher-Nachher-Ansatz“ vorgenommen werden. Des Weiteren ist eine Risikoadjustierung der Patienten unter Verwendung von einheitlichen Risikoscores zu fordern. In diesem Sinne definiert sich Qualität als dokumentiertes Bemühen um ständige Ergebnisverbesserung. Von grundsätzlicher Bedeutung ist dabei das Selbstverständnis der behandelnden Ärzte, Kliniken und Rettungsdienste als Team.Die Umsetzung der aufgezeigten Strukturen und Maßnahmen ist flächendeckend zu fordern, und die dafür nötigen Maßnahmen und Ressourcen müssen von der Politik und der Gesellschaft mitgetragen werden. Ein solcher Ansatz wird aktuell im multizentrischen FITT-STEMI-Projekt („Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction“) verfolgt.AbstractRapid revascularization of the infarct-related artery importantly affects prognosis in the treatment of acute ST elevation myocardial infarction (STEMI). Treatment results can be improved significantly when a STEMI-specific structure of care is created and when systematic quality improvement measures are implemented.The necessary structural measures include establishing or participating in myocardial infarction networks. When local hospitals collaborate in a network, it becomes feasible to offer round-the-clock primary coronary intervention to patients of those participating hospitals that do not have a catheterization laboratory on site.Another important structural step is to acquire and install prehospital twelve-lead ECG systems capable of remote telemetric transmission. This provides a solid basis for diagnosing STEMI with speed and accuracy and can prove to be highly effective in anchoring the chain of alert and treatment. As a consequence, two important goals can be realized: (1) intentionally bypassing the noninterventional hospital, and (2) systematically bypassing the emergency room of the interventional center. Both of these measures entail important time savings.An efficient instrument for improving treatment times is the implementation of a standardized quality improvement process with formalized data collection and analysis as well as with systematic data feedback to all systems and individuals involved in the early phase of treating STEMI patients within the hospital network including the emergency medical responder systems. The positive effect of such data feedback on treatment quality is contingent on the perception by all those involved that the data obtained for each patient are absolutely valid. Thus, those data need to be verifiable and an independent monitoring process should be created.Furthermore, the systematic use of standardized risk scores should be promoted in an effort to compare and adjust patient risk when analyzing network data. It is critically important that all appropriate patients – including those with a high risk of mortality – have access to rapid interventional treatment. Only when the individual risk of treated patients is taken into account will it be possible to compare quality of care and mortality rates. In general, the comparison between different hospitals, systems and regions is highly problematic and not feasible without considering local factors. It harbors the danger of inducing changes in practice in order to compete rather than in order to advance patient care, and thus it may be counterproductive when such a comparison leads to the implication that treatment may have been inferior. Therefore, the comparison of results (e.g., treatment times and mortality rates) should be undertaken as much as possible within an established system, with the use of a “before and after” design. Quality, then, will be defined as a documented consistent effort to improve results, and this approach will be distinctly productive. It is of fundamental importance that the involved hospitals, physicians and emergency staff perceive themselves as a team.The structures and processes outlined above can and should be applied broadly. The necessary resources will need to be provided through political and societal consensus. The multicenter FITT-STEMI project (“Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction”) is currently pursuing such an approach.

Prozessentwicklung in der Herzinfarktversorgung@@@Optimizing Systems of Care for Patients with Acute Myocardial Infarction. STEMI Networks, Telemetry ECG, and Standardized Quality Improvement with Systematic Data Feedback: Netzwerkbildung, Telemetrie und standardisiertes Qualitätsmanagement mit systematischer Ergebnisrückkopplung

ZusammenfassungDie schnelle Wiedereröffnung des verschlossenen Herzkranzgefäßes ist beim akuten ST-Hebungsinfarkt (STEMI) ein wesentlicher Faktor für die Prognose des Patienten. Der Wettlauf mit der Zeit bis zur Wiedereröffnung kann aber nur gewonnen werden, wenn eine hierauf eingerichtete Basisstruktur geschaffen wird, die durch ein systematisches Qualitätsmanagement (QM) in allen Details und im Zusammenspiel begleitet und kontinuierlich optimiert wird.Zur notwendigen Basisstruktur gehört die Einrichtung eines Herzinfarktnetzes, das in einer bestimmten Region die Möglichkeit zur rund um die Uhr verfügbaren Akut-Koronarintervention schafft und auch die Krankenhäuser involviert, die selbst kein Herzkatheterlabor vor Ort zur Verfügung haben. Ein weiterer wichtiger struktureller Schritt ist die Ausrüstung des Rettungsdiensts mit Zwölf-Kanal-EKG-Systemen, die die EKG-Daten mittels Telemetrie an das Interventionszentrum übermitteln können. Dadurch können auf der Basis einer raschen und sicheren Diagnose des STEMI im Interventionszentrum und der Rückmeldung an den Rettungsdienst zwei wesentliche Ziele realisiert werden, die zu erheblichen Zeitgewinnen führen: 1. das organisierte „Bypassing der Nichtinterventionsklinik“ und 2. das systematische „Bypassing der Notaufnahme“ der Interventionsklinik.Ein effizientes Instrument zur Verbesserung des komplexen Prozessablaufs und zur Verkürzung der Zeitintervalle ist die Etablierung eines standardisierten QM-Systems. Dies beinhaltet die formalisierte Datenerfassung und -analyse sowie die systematische Ergebnisrückkopplung an alle in der Frühphase des STEMI an der Behandlung der Patienten beteiligten Personen und Systeme innerhalb des Herzinfarktnetzes. Eine wichtige Voraussetzung für den positiven Effekt einer solchen Rückkopplung auf die Ergebnisqualität ist, dass die vor Ort erfassten Daten von allen Beteiligten als nachvollziehbar und valide angesehen werden können. Daher sollten die Datendokumentation und -analyse überprüfbar gemacht werden.Bewertende Vergleiche unterschiedlicher Krankenhäuser, Rettungsdienste und Regionen zeigen sich als ausgesprochen problematisch. Hier spielen lokale Besonderheiten und auch der Einschluss oder Ausschluss von STEMI-Patienten mit hohem Mortalitätsrisiko, die unbedingt einer raschen interventionellen Behandlung zugeführt werden sollten, sowie die Gefahr eines missbräuchlichen Einsatzes aus reinen Wettbewerbsgründen eine Rolle. Vergleiche von Behandlungszeiten und Sterblichkeiten sollten daher möglichst ausschließlich innerhalb eines festen Systems vor Ort in einem „Vorher-Nachher-Ansatz“ vorgenommen werden. Des Weiteren ist eine Risikoadjustierung der Patienten unter Verwendung von einheitlichen Risikoscores zu fordern. In diesem Sinne definiert sich Qualität als dokumentiertes Bemühen um ständige Ergebnisverbesserung. Von grundsätzlicher Bedeutung ist dabei das Selbstverständnis der behandelnden Ärzte, Kliniken und Rettungsdienste als Team.Die Umsetzung der aufgezeigten Strukturen und Maßnahmen ist flächendeckend zu fordern, und die dafür nötigen Maßnahmen und Ressourcen müssen von der Politik und der Gesellschaft mitgetragen werden. Ein solcher Ansatz wird aktuell im multizentrischen FITT-STEMI-Projekt („Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction“) verfolgt.AbstractRapid revascularization of the infarct-related artery importantly affects prognosis in the treatment of acute ST elevation myocardial infarction (STEMI). Treatment results can be improved significantly when a STEMI-specific structure of care is created and when systematic quality improvement measures are implemented.The necessary structural measures include establishing or participating in myocardial infarction networks. When local hospitals collaborate in a network, it becomes feasible to offer round-the-clock primary coronary intervention to patients of those participating hospitals that do not have a catheterization laboratory on site.Another important structural step is to acquire and install prehospital twelve-lead ECG systems capable of remote telemetric transmission. This provides a solid basis for diagnosing STEMI with speed and accuracy and can prove to be highly effective in anchoring the chain of alert and treatment. As a consequence, two important goals can be realized: (1) intentionally bypassing the noninterventional hospital, and (2) systematically bypassing the emergency room of the interventional center. Both of these measures entail important time savings.An efficient instrument for improving treatment times is the implementation of a standardized quality improvement process with formalized data collection and analysis as well as with systematic data feedback to all systems and individuals involved in the early phase of treating STEMI patients within the hospital network including the emergency medical responder systems. The positive effect of such data feedback on treatment quality is contingent on the perception by all those involved that the data obtained for each patient are absolutely valid. Thus, those data need to be verifiable and an independent monitoring process should be created.Furthermore, the systematic use of standardized risk scores should be promoted in an effort to compare and adjust patient risk when analyzing network data. It is critically important that all appropriate patients – including those with a high risk of mortality – have access to rapid interventional treatment. Only when the individual risk of treated patients is taken into account will it be possible to compare quality of care and mortality rates. In general, the comparison between different hospitals, systems and regions is highly problematic and not feasible without considering local factors. It harbors the danger of inducing changes in practice in order to compete rather than in order to advance patient care, and thus it may be counterproductive when such a comparison leads to the implication that treatment may have been inferior. Therefore, the comparison of results (e.g., treatment times and mortality rates) should be undertaken as much as possible within an established system, with the use of a “before and after” design. Quality, then, will be defined as a documented consistent effort to improve results, and this approach will be distinctly productive. It is of fundamental importance that the involved hospitals, physicians and emergency staff perceive themselves as a team.The structures and processes outlined above can and should be applied broadly. The necessary resources will need to be provided through political and societal consensus. The multicenter FITT-STEMI project (“Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction”) is currently pursuing such an approach.